Left Lateral Side Research Articles

SUN-577 A Remarkable Case of Thyrotoxicosis Initially Caused by Graves' Disease Followed by a TSHoma

Background: Graves’ disease is the commonest cause of thyrotoxicosis while thyrotropin producing pituitary adenomas (TSHoma) are very rare and represent 2-3.5% of all pituitary adenomas. Coexistence of a TSHoma and Graves’ disease has been very rarely reported. We present a case of a lady with a TSHoma initially presenting with primary thyrotoxicosis, likely Graves’ Disease. Case: A sixty-eight year old lady was referred to our department with thyrotoxicosis, a fT4 of 20.4pmol/L (7.0-16.0) and a TSH of <0.02mIUL (0.50-4.20). A technetium pertechnetate scan was consistent with Graves’ Disease. She was treated with carbimazole for 18 months and remained clinically and biochemically euthyroid. After stopping carbimazole her fT4 started to rise but with normal TSH. This was confirmed on multiple platforms. A TRH stimulation test demonstrated a flat TSH response and a pituitary MRI showed pituitary microadenoma. Prolactin, IGF-1 and other pituitary profile were normal. She had a 11C-Metionine PET/CT and SPGR MRI scan which demonstrated high activity on the left lateral side of the pituitary fossa consistent with a functioning adenoma. She was treated with cabergoline and octreotide but failed to tolerate either. For now the patient has decided to manage this lesion conservatively. Conclusion: This is a very unusual case of thyrotoxicosis caused by two different processes in the same patient. This case highlights the need to reconsider the diagnosis of a TSHoma when faced with discordant thyroid function tests. It also highlights the utility of 11C-Methionine PET/CT scans in the diagnosis of functional endocrine tumours.

Sex‐specific lateralization during aggressive interactions in breeding king penguins

AbstractBrain and behavioral asymmetries (termed "lateralization"; e.g., preferential eye‐use) have been mostly described in controlled laboratory conditions, although striking similarities of hemispheric brain control for specific behaviors have also been shown in the wild. Visual lateralization may provide ecological advantages by allowing complementary roles played by the left–right lateral and frontal visual field in distant or close motion detection of predators or other threats. In this study, we tested for lateralization in aggressive behavior in wild king penguins (Aptenodytes patagonicus), seabirds breeding in a context of strong colonial aggressiveness, and subject to on‐land‐based predation of their egg or chick. We show that males initiated more agonistic interactions when a congener was located in their right frontal visual field and in their left lateral visual field. The results obtained in females were the exact opposite for each subdivision of their visual fields. Complementary lateralization in male and female penguins may be part of a more general phenomenon, allowing partners to coordinate their behavior during reproduction. This may be especially true during the period of courtship, during which these seasonally monogamous and monomorphic seabirds engage in mutual mate choice based on a complex and ritualized display of ornaments located on the left and right lateral sides of the head. Those results open exciting questions as to whether hemispheric control of aggression is a commonly selected phenotypic trait across colonial seabirds.

Pulmonary sequestration infant with unusual presentation, a case report

Introduction: Pulmonary sequestration (PS) is characterized by a separate segment of the lung that receives anomalous vascular supply separate from the pulmonary arteries. Here we are report a 4-year-old girl with dyspnea and recurrent pneumonia who was finally diagnosed as a case of PS.Case presentationA 4-year-old girl was admitted to Imam-Reza hospital, Mashhad city, Iran, with a history of coughing and dyspnea from two years ago. On the CXR, consolidation can be seen in the left lower lobe. As there was a high likely hood of aspiration or pneumonia following her past medical history, the patient underwent bronchoscopy. More investigation with HRCT; revealed vascular anomaly. CMRI showed no cardiac abnormality. More findings showed a large collateral artery originated from left lateral side of abdominal aorta. This collateral artery went upward to the LLLL and anastomosed directly with two large posterior segmental tributary of the left lung pulmonary veins. Hyper-vascular pattern of both lungs was also observed in the MRI.ConclusionThis condition should be suspected in any infant with recurrent respiratory distress, or in anyone with recurrent pneumonia. To avoid misdiagnosis, PS should be considered in differential diagnosis in infants with chronic cough and dyspnea.

Discovery of a New Clade Nested Within the Genus Alexandrium (Dinophyceae): Morpho-molecular Characterization of Centrodinium punctatum (Cleve) F.J.R. Taylor

Investigation of phytoplankton from East China Sea of the Pacific Ocean, offshore Réunion Island of the Indian Ocean, and the French Atlantic coast revealed a species of poorly known armored fusiform dinoflagellate. To clarify this species, morphology and phylogeny based on mitochondrial and nuclear protein gene sequence (Cox1, Cob and Hsp90) concatenated with the SSU, ITS region and LSU rDNA sequences were analysed. Epifluorescence and scanning electron microscopy observations revealed that the nucleus of the specimen was elongated, sausage-shaped and located equatorially on the left lateral side of the cell, and that the plate formula is Po, 3', 1a, 6″, 6C, 8S, 5‴, 1p, 2'‴. These morphological features indicate that the species can be assigned to Centrodinium punctatum. Interestingly, the phylogenetic analyses placed this species within the Alexandrium clade, with Alexandrium affine being its closest relative. This indicates that genus Alexandrium is not monophyletic. The most similar morphological traits between C. punctatum and Alexandrium species were the shape of apical pore plate and the arrangement of the sulcal plates. However, since there are significant morphological differences between C. punctatum and Alexandrium species, further studies are needed to clarify the relation between the morphology and molecular phylogeny of other Centrodinium-related fusiform species.

Determination of physical parameters associated with self-efficacy in patients with chronic mechanic low back pain.

Self-efficacy that is associated with various pain-related disabilities such as chronic low back pain (LBP), should be questioned besides physical assessments. To investigate the physical factors associated with self-efficacy in patients with chronic mechanic LBP. One hundred nine patients diagnosed as chronic mechanic LBP (65 females, 44 males) between 20-50 years old were included to this study. The intensity of LBP was assessed by using a 10-cm Visual Analogue Scale. For musculoskeletal fitness measurement; muscle strength, muscle endurance, and flexibility tests were applied. Functional Reach Test for balance evaluation, Self-Efficacy Scale for self-efficacy measurement, Roland-Morris Disability Questionnaire for disability level evaluation were used. We found a moderate negative correlation between self-efficacy and pain intensity (r=-0.506); a negative and strong correlation between self-efficacy and disability level (r=-0.654) (p< 0.05). Self efficacy had a significant association with right (r= 0.265) and left (r= 0.290) lateral side bending flexibility (p< 0.05). According to multiple regression analysis results, it was found that disability level had a significant effect on self-efficacy (β=-2.014; p< 0.01). Poor musculoskeletal fitness and pain intensity may cause decreasing self-efficacy but the major determinant of decreased self-efficacy was low-back related disability scores.

Small bowel evisceration: a late complication following vaginal hysterectomy

We present a case of small bowel evisceration occurring as a late complication following vaginal hysterectomy and subsequent vault prolapse.Case history: A 92-year-old female presented with sudden onset severe abdominal pain, followed by the sensation of vaginal fullness and the discovery of a large prolapse per vagina, with no history of trauma or sexual intercourse.Past medical history consisted of vaginal hysterectomy 20 years previously with a subsequent sacrospinous vault fixation.On examination, a vaginal vault prolapse was found with 3 feet of oedematous small bowel prolapsed through it. Peristalsis remained visible.An emergency laparotomy was undertaken as a joint procedure between the gynaecology and general surgery teams. The small bowel was gently manipulated back through a 3 cm defect in the vault. Once in the abdomen, it was found to be viable and no resection was required. The vault defect was closed with 1/0 Vicryl and the vault was then fixed to the left lateral side wall of the peritoneum. Routine closure of the abdomen was performed after saline washout.Recovery was complicated by a postoperative ileus requiring nasogastric tube insertion for two days. She recovered well following this and will be followed up in the gynaecology outpatient clinic.Discussion: Small bowel evisceration is a rare complication following hysterectomy. With relatively few cases reported in the literature, incidence is difficult to determine. The most commonly reported risk factors are postmenopausal atrophy, previous vaginal surgery and enterocele. Cases have been reported following both abdominal and vaginal surgical approaches, and are commonly precipitated by sexual intercourse, introduction of a foreign body into the vagina or increased intra-abdominal pressure (Gandhi and Jha 2011).Vaginal evisceration is a gynaecological emergency. Prompt recognition is vital in order to prevent compromise of intra-abdominal contents (Codd et al. 2010). Management requires a multidisciplinary approach and early transfer to theatre for urgent surgical repair; various different approaches have been described, however, if there is any question about organ viability exploration via a midline laparotomy is indicated (Gandhi and Jha 2011).Educational message/learning point: We have presented this case in order to raise awareness of small bowel evisceration as a late complication following hysterectomy. Clinicians in both general surgery and gynaecology should be aware of its potentially non-specific presenting symptoms, as eviscerated organs may not be particularly evident on admission. This is a life threatening condition that requires immediate recognition and management via a multidisciplinary approach.

The plane mixed problem for an elastic semi-strip under different load types at its short edge

The mixed problem for the fixed semi-strip is investigated in this article for the three cases of the applied mechanical load. The solution of the boundary problem is reduced to the solution of the singular integral equation (SIE) with regard to the unknown displacements derivative. Three cases of SIE are investigated: when the mechanical load is applied on the center of the semi-strips edge, when the mechanical load is distributed near the left lateral side and when the mechanical load is distributed on the whole semi-strip’s edge. In the first case SIE is solved by the using of the orthogonal polynomials method. In the second and third cases the corresponding transcendental equations to SIE are constructed, and the SIE are solved with the help of the generalized method. The stress state of the semi-strip is investigated for the three cases.

Microtia and anotia in a dog

The aim of this case presentation is to report microtia and anotia in a 3 ‑ year ‑ old female dog. Owner complained about hearing loss and absence of auricles. There were no auricles in both control ears in clinical examination. Degree of the hearing problem was nearly deafness. A fistula was determined in left lateral cranial side. Grade III microtia and grade IV anotia were diagnosed in the ear canal of the left and right sides, respectively. Under general anesthesia, the dog underwent auricular reconstructive surgery for microtia on the left side. Two weeks after operation, the owner evaluated the patient’s hearing as moderate. This finding was clinically confirmed through performance of the Pyror’s reflex. In conclusion, grade III microtia can be treated surgically to improve the conductive hearing of the patient.

Using latex film sheet in the fresh cadaveric cow brain for the evaluating brain protection

Objective: Assessment of latex film sheet usage to protect the brain tissue against the harmful mechanical effects of metal microsurgical instruments while doing neurosurgical interventions has been the aim of this experimental study. Methods: For this experimental study, brains of cows were grouped as ones for which the latex film sheet was used (Group I) and the others the latex film sheet was not used for (Group II). The latex film sheet was sprawled over the left lateral side of the interhemispheric sulcus in Group I. Additionally, three groups of mechanical traumatic effects were created for the effects of metallic surgical instruments as “minor, moderate and severe”. Results: The results showed that there were 11 minor injured brains in Group I (n=15), with the percentage of 73. 34%. This percentage was 26. 67% with four brains in Group II (n=15) with regard to the minor injuries. When it comes to the moderately injured brain parenchyma, the numbers and percentages were 2 and 13. 33% for Group I, and 8 and 53. 33% for Group II. Severe injury numbers and percentages were 2 and 13. 33% for Group I, and 3 and 20% for Group II. Conclusions: According to the findings of this study, it can be said that the protection of brain tissue from the mechanical injury using the latex film sheet seems to be favorable. The heating effect of the operating microscope’s light is also thought to be prevented to some extent with latex film sheet implementation. On the whole, latex film sheet may have favorable effects for the practical microneurosurgery in protecting the brain tissue.

Isolated Common Hepatic Duct Injury after Blunt Abdominal Trauma

Extrahepatic bile duct injury is commonly associated with hepatic, duodenal, or pancreatic injuries, and isolated extrahepatic bile duct injury is rare. We report a patient who presented with an isolated extrahepatic bile duct injury after blunt trauma. A 50-year-old man was referred to our hospital after having suffered a fall down injury. His laboratory findings showed hyperbiliribinemia with elevated aspartate aminotransferase and alanine aminotransferase level. Initial abdominal computed tomography (CT) showed a mild degree of hemoperitoneum without evidence of abdominal solid organ injury. On the 3rd day of hospitalization, the patient complained of dyspnea and severe abdominal discomfort. Follow-up abdominal CT showed no significant interval change. Owing to the patient’s condition, Emergency laparotomy revealed a large amount of bile-containing fluid collection and about 1 cm in size laceration on the left lateral side of the common hepatic duct. Primary repair of the injured bile duct with T-tube insertion was performed On postoperative day (POD) 30, endoscopic retrograde cholangiopancreatography showed minimal bile leakage and endoscopic sphincteroplasty and endoscopic retrograde biliary drainage were performed. On POD 61, the T-tube was removed and the patient was discharged. Keywords: Abdominal injuries; Hepatic duct

Squamous Cell Carcinoma of the Tongue in a Crohnʼs Disease Patient

Case: A 36 year-old woman with CD ileocolitis presents with a new left-sided tongue lesion of 4 month's duration. There was no pain and no change in taste. She was able to scrape off the lesion but it returned. The lesion would not bleed and was not enlarging. There was no other neck swelling. Her CD had required hospitalization and small bowel resection, and has been maintained on infliximab 5 mg/kg IV every 8 weeks, azathioprine (AZA) 100 mg daily and mesalamine 2.5 g/d. Her CD has been in clinical remission for >5 years. She is a lifetime non-smoker, and does not drink alcohol. On exam, there was no submandibular, cervical or supraclavicular lymphadenopathy. There was no oral thrush, the tongue appears symmetric, and on the left lateral side is a 3 mm x 7 mm flat lesion with irregular borders (image). There were no skin lesions. Biopsy revealed superficially invasive squamous cell carcinoma (SCC), keratinizing type. The AZA was discontinued; infliximab and mesalamine continued. She underwent local excision with healing by secondary intent. Pathology confirmed a non-invasive 1.3 mm cancer, and she is thought to be cured. Discussion: The differential diagnosis of a tongue lesion in an IBD patient on immune suppression includes infectious (viral or fungal), inflammatory (lichen planus or IBD-related) and neoplastic (SCC or other) lesions. Evaluation requires careful examination and early diagnosis. IBD itself does not confer an increased risk of SCC, but exposure to AZA is a known risk factor for dermatologic and other malignancies. Tobacco and alcohol are other risk factors for SCC, but are not present in this case. Human Papilloma Virus (HPV) is another risk for SCC, but HPV-related cancers are usually more posterior in the oropharynx so that seems less likely a contributor in this case. Studies of anti-TNF have found no increased risk for SCC. Management includes discontinuation of the AZA, appropriate staging and in early stage lesions (< 3 mm deep), such as this one, surgical resection without adjuvant therapy is often curative. Clinical monitoring and close follow-up is important. Conclusions: Clinicians managing IBD should be aware of the differential diagnosis of tongue lesions and in at-risk patients, perform careful examinations and refer for early tissue diagnosis.Figure: Tongue lesion before resection.

Automated external defibrillation training on the left or the right side - a randomized simulation study.

BackgroundCorrect placement of the left automated external defibrillator (AED) electrode is rarely achieved. AED electrode placement is predominantly illustrated and trained with the rescuer sitting on the right side of the patient. Placement of the AED electrodes from the left side of the patient may result in a better overview of and access to the left lateral side of the thorax. This study aimed to investigate if training in automated external defibrillation on the left side compared to the right side of a manikin improves left AED electrode placement.MethodsLaypeople attending basic life support training were randomized to learn automated external defibrillation from the left or right side of a manikin. After course completion, participants used an AED and placed AED electrodes in a simulated cardiac arrest scenario.ResultsIn total, 40 laypersons were randomized to AED training on the left (n=19 [missing data =1], 63% female, mean age: 47.3 years) and right (n=20, 75% female, mean age: 48.7 years) sides of a manikin. There was no difference in left AED electrode placement when trained on the left or right side: the mean (SD) distances to the recommended left AED electrode position were 5.9 (2.1) cm vs 6.9 (2.2) cm (p=0.15) and to the recommended right AED electrode position were 2.6 (1.5) cm vs 1.8 (0.8) cm (p=0.06), respectively.ConclusionTraining in automated external defibrillation on the left side of a manikin does not improve left AED electrode placement compared to training on the right side.

Can an eel be a flatfish? Observations on enigmatic asymmetrical heterenchelyids from the Guinea coast of West Africa.

Morphological asymmetry is described in the heterenchelyid mud eel Pythonichthys cf. macrurus from inshore coastal waters of Guinea, West Africa. The intensity of asymmetry differs between two examined specimens, with the more extreme case exhibiting strong asymmetry in both external and internal features, including unilateral depigmentation, reductive degeneration and embedding of a blind-side eye, skewed jaws with reduced dentition and tooth loss. The extent and nature of asymmetry suggests that this individual probably lived primarily on its left lateral side, not unlike sinistral pleuronectiform flatfishes.

Determination of Isthmocele Using a Foley Catheter During Laparoscopic Repair of Cesarean Scar Defect

Study ObjectiveTo demonstrate a new technique of isthmocele repair via laparoscopic surgery. DesignCase report (Canadian Task Force classification III). The local Ethics Committee waived the requirement for approval. SettingIsthmocele localized at a low uterine segment is a defect of a previous caesarean scar due to poor myometrial healing after surgery [1]. This pouch accumulates menstrual bleeding, which can cause various disturbances and irregularities, including abnormal uterine bleeding, infertility, pelvic pain, and scar pregnancy [2–6]. Given the absence of a clearly defined surgical method in the literature, choosing the proper approach to treating isthmocele can be arduous. Laparoscopy provides a minimally invasive procedure in women with previous caesarean scar defects. InterventionA 28-year-old woman, gravida 2 para 2, presented with a complaint of prolonged postmenstrual bleeding for 5 years. She had undergone 2 cesarean deliveries. Transvaginal ultrasonography revealed a hypoechogenic area with menstrual blood in the anterior lower uterine segment. Magnetic resonance imaging showed an isthmocele localized at the anterior left lateral side of the uterus, with an estimated volume of approximately 12 cm3. After patient preparation, laparoscopy was performed. To repair the defect, the uterovesical peritoneal fold was incised and the bladder was mobilized from the lower uterine segment. During this surgery, differentiating the isthmocele from the abdomen can be challenging. Here we used a Foley catheter to identify the isthmocele. To do this, after mobilizing the bladder from the lower uterine segment, we inserted a Foley catheter into the uterine cavity through the cervical canal. We then filled the balloon of the catheter at the lower uterine segment under laparoscopic view, which allowed clear identification of the isthmocele pouch. The uterine defect was then incised. The isthmocele cavity was accessed, the margins of the pouch were debrided, and the edges were surgically reapproximated with continuous nonlocking single layer 2-0 polydioxanone sutures. We believed that single-layer suturing could provide for proper healing without necrosis due to suturation. During the procedure, the vesicouterine space was dissected without difficulty. A urine bag was collected with clear urine, and there was no gas leakage; thus, we considered a safety test for the bladder superfluous. Based on concerns about the possible increased risk of adhesions, we did not cover peritoneum over the suture. The patients experienced no associated complications, and she reported complete resolution of prolonged postmenstrual bleeding at a 3-month follow-up. ConclusionEven though the literature is cloudy in this area, a laparoscopic approach to repairing an isthmocele is a safe and minimally invasive procedure. Our approach described here involves inserting a Foley catheter in the uterine cavity through the cervical canal, then filling the balloon in the lower uterine segment under laparoscopic view to identify the isthmocele.

Endometriotic Foci in Bartholin's Cyst

Background: Endometriosis is a condition in which endometrial glands and stroma grow outside the endometrial cavity. Although endometriotic deposits are most often found within the pelvis, implants may rarely occur at several other sites. Endometriotic implants in the vulva and Bartholin's gland are very unusual. Case: A 35-year-old parous woman presented to the urogynecology clinic of the KK Women's and Children's Hospital, Singapore, with a lump arising through her vagina since a normal vaginal delivery 4 years prior. On examination, a 4 × 4 cm fluctuant, nontender vaginal cyst was noted in the lower one-third of the vagina on the left lateral side, close to an episiotomy scar. She was counseled to undergo excision of the cyst and she consented to do so. The cyst wall was inadvertently ruptured during the procedure, and a thick chocolate-colored fluid poured out from within the cyst. The cyst wall was excised and the dead space and vulval skin were closed. Results: The patient recovered well. The histopathologic examination was consistent with a Bartholin's cyst with endometriotic foci. Conclusions: Vulvar endometriosis should be considered as a possible, although rare cause of cystic masses of the vulva, especially those associated with variability in size and tenderness during the menstrual cycle. Surgical excision and histopathologic examination is necessary to establish a definitive diagnosis. (J GYNECOL SURG XX:1)

Taste function assessed by electrogustometry in burning mouth syndrome: a case-control study.

Idiopathic burning mouth syndrome (iBMS) is characterized by oral persistent pain without any clinical or biological abnormality. The aim of this study was to evaluate taste function in iBMS subjects and healthy controls. Electrogustometric thresholds (EGMt) were recorded in 21 iBMS patients and 21 paired-matched controls at nine loci of the tongue assessing fungiform and foliate gustatory papillae function. Comparison of EGMt was performed using the nonparametric Wilcoxon signed-rank test. A correlation between EGMt and self-perceived pain intensity assessed using a visual analogic scale (VAS) was analyzed with the Spearman coefficient. The level of significance was fixed at P<0.05. Mean EGMt were significantly increased with iBMS for right side of the dorsum of the tongue and right lateral side of the tongue (P<0.05). In the iBMS group, VAS scores were significantly correlated to EGMt at the tip of the tongue (r=-0.59; P<0.05) and at the right and left lateral sides of the tongue (respectively, r=-0.49 and r=-0.47; P<0.05). These data depicted impaired taste sensitivity in iBMS patients within fungiform and foliate taste bud fields and support potent gustatory/nociceptive interaction in iBMS.

Abordagem terapêutica de úlcera venosa crônica por enfermeiro especialista: relato de experiência

A insuficiência venosa crônica dos membros inferiores causa incapacidade e representar importante problema de ordem socioeconômica, pode conduzir à invalidez, levando a piora na qualidade de vida. Relatar um caso clínico de tratamento domiciliar de úlcera venosa crônica . Descrição de caso clínico com avaliação inicial, conduta terapêutica e evolução, documentado com registro fotográfico e planimetria com o programa ImageTool®. Cliente E.B., 91 anos, deambulante com auxílio, apresentando lesão em membro inferior esquerdo há 50 anos. Na avaliação inicial apresentava duas úlceras venosas: no dorso do pé esquerdo com 16,36 cm2, e em região face medial lateral da perna esquerda com 50,27 cm2. Lesões crônicas e tecido de granulação com pontos de necrose e esfacelos. Aspecto sangrante e com biofilme. Exsudato com aspecto seropurulento, amarelado, moderada quantidade, ausência de odor. Queixa de dor intensa. O tratamento foi focado no controle da colonização e redução do exsudato, optando-se por faixa compressiva e curativo com prata nanocristalizada e debridamento instrumental conforme a necessidade. Após controle do exsudato, foi utilizado hidrogel com alginato de cálcio e papaína 3%. Em oito meses, houve redução no tamanho das úlceras em 47% da região face medial lateral da perna esquerda e 85% do dorso do pé e diminuição da dor. O enfermeiro especialista é fundamental no processo de avaliação da ferida para o desenvolvimento de um plano terapêutico que compreende adequação do cuidado tópico, uso de terapia compressiva e orientações ao paciente e seu cuidador.

O54. Occupational radiation dose mapping in the hybrid interventional theatre environment evaluated at six Netcare Hospitals

Introduction The International Commission on Radiological Protection (ICRP) limits the whole body occupational exposure to < 100 mSv over five years and < 50 mSv in any single year. High occupational doses, which can exceed ICRP limits, have become a great concern in hybrid theatres due to the growing complexity of procedures and fluoroscopic time. Adherence to the As Low As Reasonably Achievable (ALARA) principle imposes that distance and shielding should be considered to avoid high staff doses. The aim of this study is to determine the high and low occupational exposure areas present in the hybrid theatres installed at Netcare Hospitals. Materials and methods Six Siemens Artis Zeego Hybrid Labs were used and 1 m2 blocks were placed in a grid pattern on the floor using masking tape. Simulation of a patient in the supine position was achieved using a PTW Normi 4 Flu Phantom. Three imaging protocols were selected for evaluation namely FL15fps, FL+30fps and LV15fps. Dose rate ( μ Gy/h) was measured inside each block at a height of 1.5 m from the floor using a RaySafe Unfors Survey Detector at three common gantry angles and the average was calculated. Results The initial results indicate that the left lateral side is the high exposure area, whereas the left posterior oblique (LPO) side is the lowest. An architectural drawing of a lab is used to illustrate results and the highest exposure for each protocol was recorded to be 257, 925 and 426 μ Gy/h, respectively. The lowest exposure area was recorded to be < 50 μ Gy/h for the outermost LPO corner. Conclusion The result is a relative approximation of high and low dose areas inside the hybrid theatres. Only scatter resulting from common projections were measured as it was not possible to measure all gantry angles. Awareness of high and low exposure areas will lead to a safer environment for radiation workers. The International Commission on Radiological Protection (ICRP) limits the whole body occupational exposure to < 100 mSv over five years and < 50 mSv in any single year. High occupational doses, which can exceed ICRP limits, have become a great concern in hybrid theatres due to the growing complexity of procedures and fluoroscopic time. Adherence to the As Low As Reasonably Achievable (ALARA) principle imposes that distance and shielding should be considered to avoid high staff doses. The aim of this study is to determine the high and low occupational exposure areas present in the hybrid theatres installed at Netcare Hospitals. Six Siemens Artis Zeego Hybrid Labs were used and 1 m2 blocks were placed in a grid pattern on the floor using masking tape. Simulation of a patient in the supine position was achieved using a PTW Normi 4 Flu Phantom. Three imaging protocols were selected for evaluation namely FL15fps, FL+30fps and LV15fps. Dose rate ( μ Gy/h) was measured inside each block at a height of 1.5 m from the floor using a RaySafe Unfors Survey Detector at three common gantry angles and the average was calculated. The initial results indicate that the left lateral side is the high exposure area, whereas the left posterior oblique (LPO) side is the lowest. An architectural drawing of a lab is used to illustrate results and the highest exposure for each protocol was recorded to be 257, 925 and 426 μ Gy/h, respectively. The lowest exposure area was recorded to be < 50 μ Gy/h for the outermost LPO corner. The result is a relative approximation of high and low dose areas inside the hybrid theatres. Only scatter resulting from common projections were measured as it was not possible to measure all gantry angles. Awareness of high and low exposure areas will lead to a safer environment for radiation workers.

Unusual venous bullet embolism – Case report

Bullet embolism is rare complication of penetrating gunshot trauma. We are presenting a case of a single gunshot with entrance wound located on external side of a left thigh. The upward directed trajectory extends to the left lateral side of the neck, but the bullet has been recovered from right external iliac vein. The bullet migration was explained due to one rare variation of the mouth of vena cava superior and inferior.

Amphioxus mouth after dorso-ventral inversion.

IntroductionDeuterostomes (animals with ‘secondary mouths’) are generally accepted to develop the mouth independently of the blastopore. However, it remains largely unknown whether mouths are homologous among all deuterostome groups. Unlike other bilaterians, in amphioxus the mouth initially opens on the left lateral side. This peculiar morphology has not been fully explained in the evolutionary developmental context. We studied the developmental process of the amphioxus mouth to understand whether amphioxus acquired a new mouth, and if so, how it is related to or differs from mouths in other deuterostomes.ResultsThe left first somite in amphioxus produces a coelomic vesicle between the epidermis and pharynx that plays a crucial role in the mouth opening. The vesicle develops in association with the amphioxus-specific Hatschek nephridium, and first opens into the pharynx and then into the exterior as a mouth. This asymmetrical development of the anterior-most somites depends on the Nodal-Pitx signaling unit, and the perturbation of laterality-determining Nodal signaling led to the disappearance of the vesicle, producing a symmetric pair of anterior-most somites that resulted in larvae lacking orobranchial structures. The vesicle expressed bmp2/4, as seen in ambulacrarian coelomic pore-canals, and the mouth did not open when Bmp2/4 signaling was blocked.ConclusionsWe conclude that the amphioxus mouth, which uniquely involves a mesodermal coelomic vesicle, shares its evolutionary origins with the ambulacrarian coelomic pore-canal. Our observations suggest that there are at least three types of mouths in deuterostomes, and that the new acquisition of chordate mouths was likely related to the dorso-ventral inversion that occurred in the last common ancestor of chordates.